Update to Practice Standards for Electrocardiographic Monitoring in Hospital Settings: A Scientific Statement From the American Heart Association

Association of Atrial Fibrillation Burden With Cardiovascular Outcomes in New-Onset Atrial Fibrillation Complicating Myocardial Infarction

BACKGROUND

New-onset atrial fibrillation (NOAF) is a common complication after acute myocardial infarction (AMI) and is associated with poor survival. Atrial fibrillation (AF) burden is used to characterize the severity of AF. However, the association of AF burden with cardiovascular outcomes in NOAF complicating AMI is poorly understood. We aimed to investigate the prognostic impact of AF burden in NOAF complicating AMI.

METHODS AND RESULTS

This multicenter retrospective cohort study included patients with AMI without a medical history of AF who developed the first documented AF during hospitalization between January 2014 and January 2022. AF burden was defined as the percentage of time spent in AF during hospitalization. The primary outcome was a composite of cardiovascular death, heart failure hospitalization, reinfarction, or ischemic stroke. A total of 812 patients with AMI and NOAF (mean age, 72.7±10.9 years; 552 men) were included. An AF burden of 15.29% was identified as the cutoff value for prognostic stratification; 663 patients with complete follow-up data were then classified into the low-burden (AF burden <15.29%; n=447) and high-burden (AF burden ≥15.29%; n=216) groups. During a median of 4.2 years of follow-up, high AF burden was associated with an increased risk of the composite outcomes (hazard ratio [HR], 1.66 [95% CI, 1.30-2.12]; P<0.001) after multivariable adjustment. When measured as a continuous scale, increasing AF burden remained an independent predictor of the composite outcomes (HR, 1.06 per 10% AF burden [95% CI, 1.02-1.09]; P=0.004).

CONCLUSIONS

A greater burden of AF is associated with a higher risk of cardiovascular outcomes among patients with NOAF complicating AMI.

Loperamide-induced severe cardiotoxicity: a toxicokinetic and toxicodynamic analysis derived from a case series and the published literature

INTRODUCTION

Chronic loperamide overdose is associated with cardiotoxicity. We describe the toxicokinetics of loperamide and N-desmethyl loperamide, and their concentration-response relationship on cardiotoxicity in newly described and published cases.

MATERIALS AND METHODS

We obtained serial loperamide and N-desmethyl loperamide concentrations, and corresponding electrocardiographic intervals in three episodes (two patients) of loperamide-related cardiotoxicity. A toxicokinetic and toxicodynamic analysis was undertaken that included data from previous publications to explore the relationship between these variables.

RESULTS

Patients presented with dizziness, bradycardia, loss of consciousness, and jerking or ventricular tachycardia after taking loperamide 320-400 mg/day for weeks or years. In one patient, ventricular tachycardia occurred on days two and three post-admission. Prolonged electrocardiographic intervals resolved after approximately five days. Admission loperamide concentrations were 5.37-288 μg/L and the terminal elimination half-lives were 21.3-38.7 h. Admission N-desmethyl loperamide concentrations were 87.67-256.34 μg/L and the terminal elimination half-life was 31.9-88.9 h. Overall, there were 42 loperamide and 35 N-desmethyl loperamide concentrations with paired electrocardiographic data, and the concentration-response relationship was derived using a maximum effect (Emax) model. Lower loperamide concentrations were associated with electrocardiographic abnormalities, compared to N-desmethyl loperamide concentrations. The total relative loperamide concentration, which combines both concentrations into a single value using in vitro inhibitory potencies at cardiac ion channels, out-performed either parent or metabolite concentrations alone for predicting cardiotoxicity on receiver operating characteristic curves.

DISCUSSION

Loperamide and N-desmethyl loperamide have long elimination half-lives causing prolonged cardiotoxicity. Higher loperamide and N-desmethyl loperamide concentrations are associated with prolonged electrocardiographic intervals.

CONCLUSIONS

Patients with chronic loperamide overdose are at risk of cardiotoxicity that persists for days due to persistent loperamide and N-desmethyl loperamide concentrations. We believe patients with loperamide overdose need an admission electrocardiograph and continuous monitoring until electrocardiographic changes resolve.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Reevaluating STEMI: The Utility of the Occlusive Myocardial Infarction Classification to Enhance Management of Acute Coronary Syndromes

BACKGROUND

The current classification of acute myocardial infarction (AMI) into ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) has limitations in identifying patients with acute coronary occlusion (ACO) who do not exhibit classic ST-elevation. Emerging evidence suggests that a reclassification to "Occlusive Myocardial Infarction" (OMI) may enhance diagnostic accuracy and therapeutic interventions.

METHODS

A comprehensive review of the literature was conducted, focusing on the pathophysiology, electrocardiographic (EKG) patterns, and management of ACO. The utility of the OMI paradigm was evaluated against the traditional STEMI/NSTEMI framework, with a particular emphasis on atypical EKG findings and their role in guiding early intervention.

RESULTS

Traditional STEMI criteria fail to identify ACO in approximately 30% of NSTEMI patients, leading to delayed reperfusion and increased mortality. The OMI framework demonstrates improved sensitivity (78.1% vs. 43.6% for STEMI criteria) for detecting ACO by incorporating subtle EKG changes, including hyperacute T-waves, de Winter T-waves, and posterior infarction patterns. OMI-guided management facilitates timely diagnosis and intervention, potentially reducing adverse outcomes. Emerging artificial intelligence (AI) tools further enhance EKG interpretation and clinical decision-making.

CONCLUSIONS

Transitioning to the OMI paradigm addresses critical gaps in the STEMI/NSTEMI framework by emphasizing the identification of ACO irrespective of ST-segment elevation. This approach could significantly improve patient outcomes by reducing delays in reperfusion therapy. Future randomized trials are needed to validate the OMI paradigm and optimize its implementation in clinical practice.

The role of telemetry monitoring: From diagnosing arrhythmia to predictive models of patient instability

Over the past sixty years, telemetry monitoring has become integral to hospital care, offering critical insights into patient health by tracking key indicators like heart rate, respiratory rate, blood pressure, and oxygen saturation. Its primary application, continuous electrocardiographic (ECG) monitoring, is essential in diverse settings such as emergency departments, step-down units, general wards, and intensive care units for the early detection of cardiac rhythms signaling acute clinical deterioration. Recent advancements in data analytics and machine learning have expanded telemetry's role from observation to prognostication, enabling predictive models that forecast inhospital events indicative of patient instability. This short communication reviews the current applications and benefits of telemetry monitoring, including its vital role in identifying arrhythmias and predicting conditions like sepsis and cardiac arrest, while also addressing challenges such as alarm fatigue and the economic impact on health systems. It further explores opportunities for developing algorithms to enhance the practical use of telemetry data in clinical settings.

Standardized Temporary Atrial Epicardial Wire Locations Lead to Enhanced Atrial Signal Identification

Background: Arrhythmias, common after pediatric cardiac surgery, are associated with increased morbidity and mortality. Atrial epicardial wires (AEW) improve diagnostic accuracy but have variable pacing and sensing properties based on their location. Even so, there are no longitudinal prospective pediatric studies examining ideal placement of AEW. Methods: This multicenter study compared atrial amplitudes, pacing sensitivities and thresholds via AEW placed at Bachmann's Bundle (BB) and the interatrial groove near the right pulmonary veins (IGRPV) versus the surgeons' standard locations. An AtriAmp system was used to obtain an atrial ECG to calculate atrial and ventricular amplitude from atrial electrograms on the bedside monitor. Sensitivities and thresholds via a temporary pacemaker were documented. ANOVA tests with repeated measures and post-hoc pairwise comparisons were performed to compare variables within the first 24-h postoperative hours. Mixed effects linear regression models were employed to examine daily trends. Results: In the first 24-h following cardiac surgery, AEW at BB and IGRPV showed significantly larger atrial amplitudes than the surgeons' standard locations. In addition, there was a negative trend in atrial ECG amplitude in all AEW from postoperative days 0 to 1; however, subsequent days showed a positive mean change in atrial amplitude with largest increase seen at BB. Atrial sensing as measured by the temporary pacemaker had statistically greater atrial signal amplitude from the BB-IGRPV set in both polarities (ie, with the BB as the - or + electrode pair) as compared to the surgeons' standard locations. No difference in atrial thresholds (mA) were noted in the immediate postoperative period or over time, with a relatively low atrial threshold at all sites. Conclusion: Standardization of AEW at Bachmann's Bundle can yield largest atrial amplitudes by atrial ECG and highest atrial sensing parameters without compromising atrial thresholds.

2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" incorporates new evidence since the "2013 ACCF/AHA Guideline for the Management of ST-Elevation Myocardial Infarction" and the corresponding "2014 AHA/ACC Guideline for the Management of Patients With Non-ST-Elevation Acute Coronary Syndromes" and the "2015 ACC/AHA/SCAI Focused Update on Primary Percutaneous Coronary Intervention for Patients With ST-Elevation Myocardial Infarction." The "2025 ACC/AHA/ACEP/NAEMSP/SCAI Guideline for the Management of Patients With Acute Coronary Syndromes" and the "2021 ACC/AHA/SCAI Guideline for Coronary Artery Revascularization" retire and replace, respectively, the "2016 ACC/AHA Guideline Focused Update on Duration of Dual Antiplatelet Therapy in Patients With Coronary Artery Disease."

METHODS

A comprehensive literature search was conducted from July 2023 to April 2024. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

A Resting ECG Screening Protocol Improved with Artificial Intelligence for the Early Detection of Cardiovascular Risk in Athletes

Background/Objectives: This study aimed to evaluate an artificial intelligence (AI)-enhanced electrocardiogram (ECG) screening protocol for improved accuracy, efficiency, and risk stratification across six sports: handball, football, athletics, weightlifting, judo, and karate. Methods: For each of the six sports, resting 12-lead ECGs from healthy children and junior athletes were analyzed using AI algorithms trained on annotated datasets. Parameters included the QTc intervals, PR intervals, and QRS duration. Statistical methods were used to examine each sport's specific cardiovascular adaptations and classify cardiovascular risk predictions as low, moderate, or high risk. Results: The accuracy, sensitivity, specificity, and precision of the AI system were 97.87%, 75%, 98.3%, and 98%, respectively. Among the athletes, 94.54% were classified as low risk and 5.46% as moderate risk with AI because of borderline abnormalities like QTc prolongation or mild T-wave inversions. Sport-specific trends included increased QRS duration in weightlifters and low QTc intervals in endurance athletes. Conclusions: The statistical analyses and the AI-ECG screening protocol showed high precision and scalability for the proposed athlete cardiovascular health risk status stratification. Additional early detection research should be conducted further for diverse cohorts of individuals engaged in sports and explore other diagnostic methods that can help increase the effectiveness of screening.

Factors Influencing Self-Confidence and Educational Needs in Electrocardiographic Monitoring Among Emergency Room and Intensive Care Unit Nurses

The self-confidence of nurses in performing electrocardiographic (ECG) monitoring is a critical competency for managing patients with cardiac conditions in high-acuity settings such as emergency rooms (ERs) and intensive care units (ICUs). This study aimed to identify the factors influencing nurses' confidence in ECG monitoring and to assess their educational needs. A total of 153 ER and ICU nurses participated in this cross-sectional study, completing structured questionnaires assessing their knowledge, confidence, and educational needs regarding ECG monitoring. The findings revealed a moderate mean confidence score of 63.47 (±15.09) out of 100. The key factors associated with higher confidence included the completion of ECG-related education, frequency of evidence searching, and clinical experience within the current department. Additionally, nurses prioritized eight critical educational topics for improving ECG-monitoring competency. These results underscore the importance of tailored educational programs and systematic training strategies to address identified gaps in knowledge and confidence. By prioritizing the specific needs of ER and ICU nurses, healthcare systems can foster supportive work environments, enhance nursing practice, and ultimately improve patient outcomes. Future research should evaluate the long-term impact of educational interventions on nurses' performance and clinical outcomes.

Assessment of conductive textile-based electrocardiogram measurement for the development of a lonely death prevention system

The rise in individuals living alone in ageing societies raises concerns about social isolation and associated health risks, notably lonely deaths among the elderly. Traditional electrocardiogram (ECG) monitoring systems, reliant on intrusive and potentially irritating electrodes, pose practical challenges. This study examines the efficacy of conductive textile electrodes (CTEs) vis-á-vis conventional electrodes (CEs) in ECG monitoring, along with the effect of electrode positioning. Twenty subjects without cardiovascular conditions, were monitored using a commercial ECG device (HiCardi+) with both CEs and CTEs. The CTEs were tested in two experiments: at the nape and left hand (position 1), and at the nape and legs (position 2). Each experiment placed one HiCardi + SmartPatch with CE at its standard position, while the other used CTEs. ECG signals were processed using the Pan-Tompkins algorithm, and heart rate variability (HRV) metrics were analysed. Significant improvements in signal-to-noise ratio (SNR) were observed after filtering. There were no significant differences (p > 0.05) in time-domain HRV metrics between CEs and CTEs, though CTEs showed superior R peak characteristics and reduced noise sensitivity. Additionally, no significant position effect (p > 0.05) was noted within the CTE group. Nonlinear analysis further confirmed the efficacy of the CTEs. Our findings suggest that CTEs offer a comfortable, non-intrusive alternative to conventional ECG electrodes, enhancing ECG monitoring and contributing to the development of a "lonely death prevention system".

Computerized QT and QTc Measurements From Bedside ICU Monitors Are Similar to Those Derived From a Standard 12-Lead ECG

QT/QTc prolongation is associated with an increased risk for torsade de pointes. In at-risk hospitalized patients, it is common to obtain a standard 12-lead electrocardiogram (ECG) for this assessment, but this interrupts patient care. Our hospital recently introduced bedside monitors in the intensive care unit (ICU) with continuous QT/QTc software. However, only four of the seven available ECG leads are used.

PURPOSE

Evaluate the agreement between computerized QT/QTc measurements from the bedside monitor (four leads) and a time-matched standard 12-lead ECG.

DESIGN

Prospective observational study in three adult ICUs.

METHODS

QT/QTc measurements were obtained from a convenience sample, and the two ECG types were ≤ 30 min apart. Agreement was evaluated using Bland-Altman analysis.

RESULTS

A total of 120 patients were evaluated for inclusion, and 60 (50%) had a 12-lead ECG for comparison. The mean bias difference for QT measurements was not statistically different (β = -2.47, 95% CI = 5.50 to -11.05; p = 0.44; limits of agreement (LOA) = -64.37 to 59.44). Similar non-statistical differences were observed for QTc (β = -3.20, 95% CI = 5.50 to -11.05; p = 0.44; LOA = -67.43 to 61.03).

CONCLUSION

There was good agreement for both QT and QTc measurements between the two methods. These pilot data are promising and suggest QT/QTc measurements from bedside monitors (four leads) may be an acceptable alternative to obtaining additional standard 12-lead ECGs. Given that half of the ICU patients screened did not have a 12-lead ECG recorded, bedside monitor QT/QTc's could identify at-risk patients. However, an evaluation in a larger sample and non-ICU patients is warranted.

Agreement of Computerized QT and QTc Interval Measurements Between Both Bedside and Expert Nurses Using Electronic Calipers

BACKGROUND

In hospitalized patients, QT/QTc (heart rate corrected) prolongation on the electrocardiogram (ECG) increases the risk of torsade de pointes. Manual measurements are time-consuming and often inaccurate. Some bedside monitors automatically and continuously measure QT/QTc; however, the agreement between computerized versus nurse-measured values has not been evaluated.

OBJECTIVE

The aim of this study was to examine the agreement between computerized QT/QTc and bedside and expert nurses who used electronic calipers.

METHODS

This was a prospective observational study in 3 intensive care units. Up to 2 QT/QTc measurements (milliseconds) per patient were collected. Bland-Altman test was used to analyze measurement agreement.

RESULTS

A total of 54 QT/QTc measurements from 34 patients admitted to the ICU were included. The mean difference (bias) for QT comparisons was as follows: computerized versus expert nurses, -11.04 ± 4.45 milliseconds (95% confidence interval [CI], -2.3 to -19.8; P = .016), and computerized versus bedside nurses, -13.72 ± 6.70 (95% CI, -0.70 to -26.8; P = .044). The mean bias for QTc comparisons was as follows: computerized versus expert nurses, -12.46 ± 5.80 (95% CI, -1.1 to -23.8; P = .035), and computerized versus bedside nurses, -18.49 ± 7.90 (95% CI, -3.0 to -33.9; P = .022).

CONCLUSION

Computerized QT/QTc measurements calculated by bedside monitor software and measurements performed by nurses were in close agreement; statistically significant differences were found, but differences were less than 20 milliseconds (on-half of a small box), indicating no clinical significance. Computerized measurements may be a suitable alternative to nurse-measured QT/QTc. This could reduce inaccuracies and nurse burden while increasing adherence to practice recommendations. Further research comparing computerized QT/QTc from bedside monitoring to standard 12-lead electrocardiogram in a larger sample, including non-ICU patients, is needed.

Appropriateness and outcomes of hospitalized patients telemetry monitored for cardiac arrhythmias in accordance with the American Heart Association Practice Standards-A multicenter study

BACKGROUND

To the best of our knowledge, no prospective research studies have compared clinical practice to the American Heart Association (AHA) updated practice standards for in-hospital telemetry monitoring.

OBJECTIVES

Our aims were therefore (1) to investigate how patients were assigned to telemetry monitoring in accordance with the AHA's updated practice standards, (2) to determine the number and type of arrhythmic events, and (3) to describe subsequent changes in clinical management.

METHODS

This prospective multicenter study included 1154 patients at three university hospitals in Norway. Data were collected 24/7 over a four-week period, with follow-up measurements from telemetry admission until hospital discharge.

RESULTS

Of patients assigned to telemetry, 67 % (n = 767) met practice standards, corresponding to AHA Class I or II. Patients were predominantly men (65 %, n = 748), and the mean age was 65 years (SD ±16). The study included both patients with cardiac and non-cardiac diagnoses from various medical and surgical departments throughout the hospitals. Ninety-one percent of the patients in Class III were monitored based on indications that were reclassified from Class II to Class III (not indicated) in the updated practice standards (patients admitted with chest pain or post-percutaneous coronary intervention (PCI) without complications). Overall, arrhythmic events occurred in 37 % (n = 424) of patients, and they occurred in all classes. Eighteen percent (n = 59) of arrhythmic events occurred in Class III. Of all arrhythmias, 3 % (n = 14) were life threatening, and all of them occurring within Class I. Telemetry monitoring led to changes in clinical management in 22 % (n = 257) of patients due to clinical alarms, of which 71 % (n = 182) were related to medication management.

CONCLUSIONS

Most patients were appropriately monitored according to the AHA practice standards, meeting Class I and II. Arrhythmias occurred in all classes, but life-threatening arrhythmias only occurred in patients in Class I. However, a daily re-assessment of each patient's telemetry indication is warranted.

Advanced Noise-Resistant Electrocardiography Classification Using Hybrid Wavelet-Median Denoising and a Convolutional Neural Network

The classification of ECG signals is a critical process because it guides the diagnosis of the proper treatment process for the patient. However, any form of disturbance with ECG signals can be highly conspicuous because of the mechanics involved in data acquisition from living beings, which has a significant impact on the classification procedure. The purpose of this research work is to advance ECG signal classification results by employing numerous denoising methods and, in turn, boost the accuracy of cardiovascular diagnoses. To simulate realistic conditions, we added various types of noise to ECG data, including Gaussian, salt and pepper, speckle, uniform, and exponential noise. To overcome the interference of noise from environments in the obtained ECG signals, we employed wavelet transform, median filter, Gaussian filter, and the hybrid of the wavelet and median filters. The proposed hybrid denoising method has better results than the other methods because of the use of wavelet multi-scale analysis and the ability of the median filter to avoid the loss of vital ECG characteristics. Thus, despite a certain proximity in the values, the hybrid method is significantly more accurate and reliable, as evidenced by the mean squared error (MSE), mean absolute error (MAE), R-squared, and Pearson correlation coefficient. More specifically, the hybrid approach provided an MSE of 0.0012 and an MAE of 0.025, the R-squared value for this study was 0.98, and the Pearson correlation coefficient was 0.99, which provides a very good resemblance to the original ECG confirmation. The proposed classification model is based on the modified lightweight CNN or MLCNN that was trained using the noisy and the denoised data. The findings demonstrated that by applying the denoised data, the testing accuracy, precision, recall, and F1 scores achieved 0.92, 0.91, 0.90, and 0.91 for the datasets, while the noisy data achieved 0.80, 0.78, 0.82, and 0.80, respectively. In this study, the signal quality and denoising methods were found to enhance ECG signal classification and diagnostic accuracy while encouraging proper preprocessing in future studies and applications for real-time ECG for cardiac care.

Amiodarone Therapy: Updated Practical Insights

Amiodarone, a bi-iodinated benzofuran derivative, is among the most commonly used antiarrhythmic drugs due to its high level of effectiveness. Though initially categorized as a class III agent, amiodarone exhibits antiarrhythmic properties across all four classes of antiarrhythmic drugs. Amiodarone is highly effective in maintaining sinus rhythm in patients with paroxysmal atrial fibrillation while also playing a crucial role in preventing a range of ventricular arrhythmias. Amiodarone has a complex pharmacokinetic profile, characterized by a large volume of distribution and a long half-life, which can range from several weeks to months, resulting in prolonged effects even after discontinuation. Side effects may include thyroid dysfunction, pulmonary fibrosis, and hepatic injury, necessitating regular follow-ups. Additionally, amiodarone interacts with several drugs, including anticoagulants, which must be managed to prevent adverse effects. Therefore, a deep understanding of both oral and intravenous formulations, as well as proper dosage adjustments, is essential. The aim of this paper is to provide a comprehensive and updated review on amiodarone's indications, contraindications, recommended dosages, drug interactions, side effects, and monitoring protocols.

The ECG abnormalities in persons with chronic disorders of consciousness

We aimed to investigate the electrocardiogram (ECG) features in persons with chronic disorders of consciousness (DOC, ≥ 29 days since injury, DSI) resulted from the most severe brain damages. The ECG data from 30 patients with chronic DOC and 18 healthy controls (HCs) were recorded during resting wakefulness state for about five minutes. The patients were classified into vegetative state (VS) and minimally conscious state (MCS). Eight ECG metrics were extracted for comparisons between the subject subgroups, and regression analysis of the metrics were conducted on the DSI (29-593 days). The DOC patients exhibit a significantly higher heart rate (HR, p = 0.009) and lower values for SDNN (p = 0.001), CVRR (p = 0.009), and T-wave amplitude (p < 0.001) compared to the HCs. However, there're no significant differences in QRS, QT, QTc, or ST amplitude between the two groups (p > 0.05). Three ECG metrics of the DOC patients-HR, SDNN, and CVRR-are significantly correlated with the DSI. The ECG abnormalities persist in chronic DOC patients. The abnormalities are mainly manifested in the rhythm features HR, SDNN and CVRR, but not the waveform features such as QRS width, QT, QTc, ST and T-wave amplitudes.

Optimizing Decision Support Alerts to Reduce Telemetry Duration: A Multicenter Evaluation

BACKGROUND

 Telemetry monitoring is crucial for high-risk patients but excessive use beyond practice standards increases costs. Prior studies have shown that electronic health record (EHR) alerts reduce low-value telemetry monitoring. However, specific components of these alerts that contribute to effectiveness are unknown.

OBJECTIVES

 We aimed to revise previously implemented EHR Best Practice Advisories (BPAs) to optimize their effectiveness in reducing telemetry duration. The secondary objective was to assess the impact on clinicians' alert burden.

METHODS

 A multicenter retrospective study was conducted at Johns Hopkins Hospital (JHH), Johns Hopkins Bayview Medical Center (JHBMC), and Howard County General Hospital (HCGH). An EHR alert in the form of a BPA was previously implemented at JHH/JHBMC, firing at 24, 48, or 72 hours based on order indication. HCGH used an alert firing every 24 hours. A revised BPA was implemented at all hospitals optimizing the prior JHH/JHBMC alert by including patient-specific telemetry indications, restricting alerts to daytime hours (8:00 a.m.-6:00 p.m.), and embedding the discontinuation order within the BPA alert. A retrospective analysis from October 2018 to December 2021 was performed. The primary outcome was telemetry duration. The secondary outcome was the mean monthly BPA alerts per patient-day.

RESULTS

 Compared with the original BPA, the revised BPA reduced telemetry duration by a mean of 6.7 hours (95% CI: 5.2-9.1 hours, p < 0.001) at JHH/JHBMC, with a minimal increase of 0.06 mean monthly BPA alerts per patient-day (p < 0.001). The BPA acceptance rate increased from 7.8 to 31.3% postintervention at JHH/JHBMC (p < 0.0001). At HCGH, the intervention led to a mean monthly reduction of 20.2 hours in telemetry duration per hospitalization (95% CI: 19.1-22.8 hours, p < 0.0001).

CONCLUSION

 Optimizing EHR BPAs reduces unnecessary telemetry duration without substantially increasing clinician alert burden. This study highlights the importance of tailoring EHR alerts to enhance effectiveness and promote value-based care.

Continuous Electrocardiographic Monitoring for 24 Hours Before Death in Patients with Terminal Cancer

BACKGROUND

Purposeless physiological monitoring at the end-of-life is not recommended. However, studies on how families feel regarding the death of patients with terminal cancer without continuous electrocardiographic monitoring (CEM) are lacking.

OBJECTIVES

To explore the impact on the quality of care and the feelings and psychological distress experienced by families when CEM is not used during the 24 hours preceding a patient's death.

METHODS

In this multicenter cross-sectional, self-report questionnaires were distributed to 1087 bereaved families at Japanese specialized palliative care units in 2018.

RESULTS

Out of 671 responses, 394 valid responses were analyzed. Families of nonmonitored patients (NM-group) accounted for 79.2%, while those with bedside electrocardiogram monitoring (MB-group) and remote nurse station monitoring (MC-group) comprised 11.9% and 8.9%, respectively. In the NM-group, 85.5% expressed satisfaction without CEM, which was more than 10% lower than other groups. While 14% in the NM-group desired patient monitoring, families who received adequate explanations about CEM had lower proportions compared to the MB-group (P = .021). Univariate analyses showed no significant differences in evaluations of the quality of care and families' psychological distress (mean scores of Overall Care Satisfaction, Care Evaluation Scale, Good Death Inventory, Brief Grief Questionnaires) across all groups.

CONCLUSION

While the majority of NM-group were satisfied with their patient's care without CEM, the proportion of dissatisfied families was higher than in other groups. Although not using CEM is not a major hindrance to end-of-life care for patients with terminal cancer, providing sufficient explanations may be important for satisfactory care.

Effectiveness of electrocardiogram interpretation education program using mixed learning methods and webpage

AIM

This study was conducted to develop an electrocardiogram education program that incorporates an HTML webpage and blended learning methods to enhance electrocardiogram interpretation skills. Through continual and efficient education, the program aims to assist nurses in providing appropriate care and treatment to patients.

DESIGN

Pre-post design study.

METHODS

We developed an electrocardiogram interpretation HTML webpage based on an electrocardiogram interpretation algorithm and implemented an 18-week (2023.5.15 ~ 2023.9.22) electrocardiogram education program, which included daily 5-minute training sessions. Twenty-seven ward nurses were provided with the URL ( https://ecgweb.github.io/ECGwebEN ) to the electrocardiogram interpretation HTML webpage and shared one electrocardiogram case daily for self-interpretation. Electrocardiogram interpretation performance and confidence were evaluated through questionnaires at three phases: before the program, after 6 weeks of basic electrocardiogram and arrhythmia education, and after 12 weeks of application of the electrocardiogram interpretation HTML webpage and case-based lecture education. The statistical tests used were repeated-measures ANOVA or the Wilcoxon signed-rank test.

RESULTS

The average score for electrocardiogram interpretation performance before the electrocardiogram education program was 11.89(SD = 3.50), after 6 weeks of basic electrocardiogram and arrhythmia education it was 14.15(SD = 3.68), and after 12 weeks of application of the electrocardiogram interpretation HTML webpage and case-based lecture education, it was 15.56(SD = 3.04). This shows that electrocardiogram interpretation performance significantly improved over time (p < .001). Additionally, post-hoc analysis revealed significant differences in electrocardiogram interpretation performance at each stage, i.e., before, during, and after the application of an electrocardiogram education program. Furthermore, the electrocardiogram interpretation confidence questionnaire score (pre-Median 18, IQR = 5; post-Median 23, IQR = 3) was improved significantly after the completion of the 18-week education program (p < .001).

CONCLUSIONS

Based on the results of this study, we believe that an electrocardiogram education program using HTML webpage, and a blended teaching method would be very beneficial for maintaining and improving electrocardiogram interpretation skills of clinical nurses. Such a program can help nurses interpret electrocardiograms more effectively and assist them in making important decisions in patient care.

Analysis of ST segment alarms in children admitted to the paediatric and cardiac intensive care units and cardiac progressive care unit: a single-centre retrospective study

ST segment monitoring in the adult population allows for the early detection of myocardial ischaemia. In children admitted to the paediatric intensive care unit (PICU), cardiac intensive care unit (CICU), and cardiac progressive care unit (CPCU), it is unclear if continuous ST segment alarm monitoring is necessary in all patients. All patients admitted to the PICU, CICU, and CPCU during the study period were included. Children with any ST segment alarms were compared with those without an alarm during their stay. The electrocardiogram confirmed true ST segment alarms were compared with all other ST segment alarms. Demographic and clinical data were extracted from the medical record. Medical interventions and procedures occurring around ST segment alarms were recorded for multivariable analysis assessing for the association of true ST segment. Logistic regression was used to evaluate the associations with ST segment alarms during hospital stays. ST segment alarms occurred in 36% of hospital stays, and only 3.4% were considered true. True alarms were significantly more common among patients with a cardiac-related diagnosis, located in both cardiac units, and having received an intervention with any vasoactive medication. In the multivariable logistic regression, patients 11 years or older, hypotension, supraventricular tachycardia, and initiation/escalation of any vasoactive were independently associated with a true ST segment alarm. True ST segment alarms were infrequent, occurring in 1.2% of stays during the study period. Alarm monitoring may be beneficial in those with an underlying cardiac diagnosis.

Registered nurses' knowledge and interpretation of ECG rhythms: A cross-sectional study

BACKGROUND

Electrocardiographic (ECG) monitoring and recording are seen as the most commonly used non-invasive diagnostic tool to identify cardiac arrhythmia and myocardial damage in the clinical setting. There is an expectation that critical care nurses are ideally trained to interpret abnormalities and morphology in the ECG more proficiently than nurses from general ward areas. However, the ability to interpret and recognise ECG abnormalities is dependent on which critical care area nurses are currently working in and their level of experience.

AIM

The aim of this study was to investigate registered nurses' knowledge in being able to identify and interpret select electrocardiographic rhythms.

STUDY DESIGN

This was a cross-sectional study that evaluated registered nurses' knowledge of electrocardiogram rhythm identification and interpretation. A convenience sample of 105 registered nurses currently enrolled in a 2-year Master's programme leading to critical care specialism and advanced practice nurse award were recruited. A 20-item multiple choice questionnaire that provided examples of electrocardiogram rhythm (n=14) abnormalities and rhythm abnormalities caused by electrolyte disturbances (n=6) RESULTS: The study included registered nurses from critical care and general ward areas. The overall results were poor with only 55% of questions answered correctly. Coronary care nurses scored the highest in identifying ECG rhythms (12/20 ± 1.58; p < .001). When ECG abnormalities associated with electrolyte imbalances were analysed, both groups were unable to identify the effects of hypokalaemia and hypomagnesaemia effectively (p = .748). Length of time as a registered nurse (r = -0.304, p = .002) and length of time in current work environment were weakly correlated (r = -0.328, p = .001). Having a critical care background showed a positive relationship with nursing knowledge of ECG rhythm identification (r = 0.614, p < .001).

CONCLUSION

The results of this study demonstrate that nurses have a poor knowledge of ECG rhythm identification and interpretation, a consistent finding from other work. A possible solution is a revamp of education and training associated with ECG recognition and morphology.

RELEVANCE TO CLINICAL PRACTICE

Monitoring and assessing ECG morphology provide important details about cardio-electroconductive stability, especially with fluctuations in serum electrolyte levels seen in critical illness or trauma. For this, critical nurses must improve their proficiency through education/training or internal quality improvement activities in detecting abnormalities associated with ECG changes beyond those most easily recognizable rhythms such as atrial fibrillation or ventricular tachycardia.

Understanding provider use of a new clinical decision support tool aimed at reducing excess telemetry in an academic health system: A retrospective study

RATIONALE

Cardiac monitoring has often been identified as an area of overutilization and remains a limited resource in many hospitals. With the aim of reducing telemetry overuse, we added clinical decision support to our health system's telemetry order with guidance on appropriate indications for monitoring. The new order requires selection of an appropriate clinical indication.

AIMS AND OBJECTIVES

In this study, we aimed to understand provider engagement with this tool by assessing concordance between selected indications within the order and the clinical presence of those conditions as documented within the patient chart.

METHODS

We randomly selected 100 telemetry orders from July to October 2022 across four different hospitals at NYU Langone Health. Two independent, blinded reviewers used a structured protocol to identify documentation of actual indications for telemetry in each selected chart. We calculated the rate of concordance between indications selected in the order and indications that were determined to be clinically present on chart review.

RESULTS

There were 30,839 telemetry orders placed during the study timeframe. Overall concordance between the selection within the order and the actual indication was 48% (95% confidence interval [CI], 38.21%-57.79%). We observed especially low concordance rates for vague indications, such as 'Other', and for 'Confirmed Stroke', which was the only indication allowing for indefinite telemetry.

CONCLUSION

The overall low concordance suggests a disconnect between the support tool and clinical practice. Providers are more likely to select an indication that reduces downstream work regardless of a patient's true clinical indication.

Same-day discharge vs. overnight stay following catheter ablation for atrial fibrillation: a comprehensive review and meta-analysis by the European Heart Rhythm Association Health Economics Committee

AIMS

Same-day discharge (SDD) after catheter ablation of atrial fibrillation (AF) may address the growing socio-economic health burden of the increasing demand for interventional AF therapies. This systematic review and meta-analysis analyses the current evidence on clinical outcomes in SDD after AF ablation compared with overnight stay (ONS).

METHODS AND RESULTS

A systematic search of the PubMed database was performed. Pre-defined endpoints were complications at short-term (24-96 h) and 30-day post-discharge, re-hospitalization, and/or emergency room (ER) visits at 30-day post-discharge, and 30-day mortality. Twenty-four studies (154 716 patients) were included. Random-effects models were applied for meta-analyses of pooled endpoint prevalence in the SDD cohort and for comparison between SDD and ONS cohorts. Pooled estimates for complications after SDD were low both for short-term [2%; 95% confidence interval (CI): 1-5%; I2: 89%) and 30-day follow-up (2%; 95% CI: 1-4%; I2: 91%). There was no significant difference in complications rates between SDD and ONS [short-term: risk ratio (RR): 1.62; 95% CI: 0.52-5.01; I2: 37%; 30 days: RR: 0.65; 95% CI: 0.42-1.00; I2: 95%). Pooled rates of re-hospitalization/ER visits after SDD were 4% (95% CI: 1-10%; I2: 96%) with no statistically significant difference between SDD and ONS (RR: 0.86; 95% CI: 0.58-1.27; I2: 61%). Pooled 30-day mortality was low after SDD (0%; 95% CI: 0-1%; I2: 33%). All studies were subject to a relevant risk of bias, mainly due to study design.

CONCLUSION

In this meta-analysis including a large contemporary cohort, SDD after AF ablation was associated with low prevalence of post-discharge complications, re-hospitalizations/ER visits and mortality, and a similar risk compared with ONS. Due to limited quality of current evidence, further prospective, randomized trials are needed to confirm safety of SDD and define patient- and procedure-related prerequisites for successful and safe SDD strategies.

Hospital-Based Electrocardiographic Monitoring: The Good, the Not So Good, and Untapped Potential

Continuous electrocardiographic (ECG) monitoring was first introduced into hospitals in the 1960s, initially into critical care, as bedside monitors, and eventually into step-down units with telemetry capabilities. Although the initial use was rather simplistic (ie, heart rate and rhythm assessment), the capabilities of these devices and associated physiologic (vital sign) monitors have expanded considerably. Current bedside monitors now include sophisticated ECG software designed to identify myocardial ischemia (ie, ST-segment monitoring), QT-interval prolongation, and a myriad of other cardiac arrhythmia types. Physiologic monitoring has had similar advances from noninvasive assessment of core vital signs (blood pressure, respiratory rate, oxygen saturation) to invasive monitoring including arterial blood pressure, temperature, central venous pressure, intracranial pressure, carbon dioxide, and many others. The benefit of these monitoring devices is that continuous and real-time information is displayed and can be configured to alarm to alert nurses to a change in a patient's condition. I think it is fair to say that critical and high-acuity care nurses see these devices as having a positive impact in patient care. However, this enthusiasm has been somewhat dampened in the past decade by research highlighting the shortcomings and unanticipated consequences of these devices, namely alarm and alert fatigue. In this article, which is associated with the American Association of Critical-Care Nurses' Distinguished Research Lecture, I describe my 36-year journey from a clinical nurse to nurse scientist and the trajectory of my program of research focused primarily on ECG and physiologic monitoring. Specifically, I discuss the good, the not so good, and the untapped potential of these monitoring systems in clinical care. I also describe my experiences with community-based research in patients with acute coronary syndrome and/or heart failure.

Evaluation of a Clinical Decision Support Tool to Guide Adoption of the American Heart Association Telemetry Monitoring Practice Standards

BACKGROUND

The objectives of this study were to (1) evaluate telemetry use pre- and postimplementation of clinical decision support tools to support American Heart Association practice standards for telemetry monitoring and (2) understand the factors that may contribute to variation of telemetry monitoring in practice.

METHODS AND RESULTS

First, we captured overall variability in telemetry use pre- and postimplementation of the clinical decision support intervention. We then conducted semistructured interviews with telemetry-ordering providers to identify key barriers and facilitators to adoption. During the study period, 399 physicians met criteria for inclusion and were divided into excessive and nonexcessive orderers. Distribution of telemetry use was bimodal. Among nonexcessive users, 24.4% of patient days were with telemetry compared with 51.6% among excessive users. On average, both excessive (6.1% reduction) and nonexcessive users (2.8% reduction) decreased telemetry use postimplementation, and these reductions were sustained over a 16-month period. Sixteen interviews were conducted. Physicians believed that the tool was successful because it caused them to more closely consider if telemetry was indicated for each patient. Physicians also voiced frustration with interruptions to their workflow, and some noted that they commonly use telemetry outside of practice standards to monitor patients who were acutely but not critically ill.

CONCLUSIONS

Embedding telemetry practice standards into the electronic health record in the form of clinical decision support is effective at reducing excess telemetry use. Although the intervention was well received, there are persistent barriers, such as preexisting views on telemetry and existing workflow habits, that may inhibit higher adoption of standards.

ECG signal quality in intermittent long-term dry electrode recordings with controlled motion artifacts

Wearable long-term monitoring applications are becoming more and more popular in both the consumer and the medical market. In wearable ECG monitoring, the data quality depends on the properties of the electrodes and on how they interface with the skin. Dry electrodes do not require any action from the user. They usually do not irritate the skin, and they provide sufficiently high-quality data for ECG monitoring purposes during low-intensity user activity. We investigated prospective motion artifact-resistant dry electrode materials for wearable ECG monitoring. The tested materials were (1) porous: conductive polymer, conductive silver fabric; and (2) solid: stainless steel, silver, and platinum. ECG was acquired from test subjects in a 10-min continuous settling test and in a 48-h intermittent long-term test. In the settling test, the electrodes were stationary, whereas both stationary and controlled motion artifact tests were included in the long-term test. The signal-to-noise ratio (SNR) was used as the figure of merit to quantify the results. Skin-electrode interface impedance was measured to quantify its effect on the ECG, as well as to leverage the dry electrode ECG amplifier design. The SNR of all electrode types increased during the settling test. In the long-term test, the SNR was generally elevated further. The introduction of electrode movement reduced the SNR markedly. Solid electrodes had a higher SNR and lower skin-electrode impedance than porous electrodes. In the stationary testing, stainless steel showed the highest SNR, followed by platinum, silver, conductive polymer, and conductive fabric. In the movement testing, the order was platinum, stainless steel, silver, conductive polymer, and conductive fabric.

The patient experience of in-hospital telemetry monitoring: a qualitative analysis

AIMS

In-hospital telemetry monitoring has been an integrated part of arrhythmia monitoring for decades. A substantial proportion of patients require arrhythmia monitoring during stays in non-intensive care units. However, studies exploring patients' experiences of telemetry monitoring are scarce. Therefore, the aim was to explore and describe patients' experiences of in-hospital telemetry monitoring in a non-intensive care setting.

METHODS AND RESULTS

Twenty face-to-face, semi-structured interviews were conducted. Interviews were conducted before discharge at two university hospitals in Norway. The patients were purposively sampled, resulting in a well-balanced population comprising 11 men and nine women, mean age 62 years (range 25-83). Average monitoring time was 9 days (range 3-14). Data were audiotaped, transcribed verbatim, and coded using NVivo software. Qualitative content analysis using an inductive approach was performed. Patients expressed a need for individualized information during telemetry monitoring. Their feelings of safety were related to responses from nurses from the central monitoring station when alarms from the telemetry were triggered. Despite perceived physical restrictions and psychological limitations associated with telemetry monitoring, they found monitoring to be beneficial because it facilitated the diagnosis of arrhythmia. Moreover, they expressed a need for improvements in wearable monitoring equipment. Patients expressed ambivalent feelings about discontinuing the telemetry and their readiness for discharge.

CONCLUSION

Patients need individualized information about the results of their telemetry monitoring in order to better understand the arrhythmia management and to increase their experience of safety after discharge. The limitations patients experienced should be taken into consideration in further upgrades of telemetry monitoring equipment.

Prevalence and prognostic value of electrocardiographic abnormalities in hypokalemia: A multicenter cohort study

BACKGROUND

Hypokalemia is common in hospitalized patients and associated with ECG abnormalities. The prevalence and prognostic value of ECG abnormalities in hypokalemic patients are, however, not well established.

METHODS

The study was a multicentered cohort study, including all ault patients with an ECG and potassium level <4.4 mmol/L recorded at arrival to four emergency departments in Denmark and Sweden. Using computerized measurements from ECGs, we investigated the relationship between potassium levels and heart rate, QRS duration, corrected QT (QTc) interval, ST-segment depressions, T-wave flattening, and T-wave inversion using cubic splines. Within strata of potassium levels, we further estimated the hazard ratio (HR) for 7-day mortality, admission to the intensive care unit (ICU), and diagnosis of ventricular arrhythmia or cardiac arrest, comparing patients with and without specific ECG abnormalities matched 1:2 on propensity scores.

RESULTS

Among 79,599 included patients, decreasing potassium levels were associated with a concentration-dependent increase in all investigated ECG variables. ECG abnormalities were present in 40% of hypokalemic patients ([K+ ] <3.5 mmol/L), with T-wave flattening, ST-segment depression, and QTc prolongation occurring in 27%, 16%, and 14%. In patients with mild hypokalemia ([K+ ] 3.0-3.4 mmol/L), a heart rate >100 bpm, ST-depressions, and T-wave inversion were associated with increased HRs for 7-day mortality and ICU admission, whereas only a heart rate >100 bpm predicted both mortality and ICU admission among patients with [K+ ] <3.0 mmol/L. HR estimates were, however, similar to those in eukalemic patients. The low number of events with ventricular arrhythmia limited evaluation for this outcome.

CONCLUSIONS

ECG abnormalities were common in hypokalemic patients, but they are poor prognostic markers for short-term adverse events under the current standard of care.

Performance comparison of 6 in-hospital patient monitoring systems in the detection and alarm of ventricular cardiac arrhythmias

Background

Patient monitoring devices are critical for alerting of potential cardiac arrhythmias during hospitalization; however, there are concerns of alarm fatigue due to high false alarm rates.

Objective

The purpose of this study was to evaluate the sensitivity and false alarm rate of hospital-based continuous electrocardiographic (ECG) monitoring technologies.

Methods

Six commonly used multiparameter bedside monitoring systems available in the United States were evaluated: B125M (GE HealthCare), ePM10 and iPM12 (Mindray), Efficia and IntelliVue (Philips), and Life Scope (Nihon Kohden). Sensitivity was tested using ECG recordings containing 57 true ventricular tachycardia (VT) events. False-positive rate testing used 205 patient-hours of ECG recordings containing no cardiac arrhythmias. Signals from ECG recordings were fed to devices simultaneously; high-severity arrhythmia alarms were tracked. Sensitivity to true VT events and false-positive rates were determined. Differences were assessed using Fisher exact tests (sensitivity) and Z-tests (false-positive rates).

Results

B125M raised 56 total alarms for 57 annotated VT events and had the highest sensitivity (98%; P <.05), followed by iPM12 (84%), Life Scope (81%), Efficia (79%), ePM10 (77%), and IntelliVue (75%). B125M raised 20 false alarms, which was significantly lower (P <.0001) than iPM12 (284), Life Scope (292), IntelliVue (304), ePM10 (324), and Efficia (493). The most common false alarm was VT, followed by nonsustained VT.

Conclusion

We found significant performance differences among multiparameter bedside ECG monitoring systems using previously collected recordings. B125M had the highest sensitivity in detecting true VT events and lowest false alarm rate. These results can assist in minimizing alarm fatigue and optimizing patient safety by careful selection of in-hospital continuous monitoring technology.

Unraveling Wavy ST Segments-An Unusual Case of Syncope

This case report describes a patient in their 60s with gastroesophageal reflex disease who presented to the emergency department after loss of consciousness during dinner and daily intermittent chest discomfort.

Pharmacist Reported Protocols for QTc Monitoring of Psychiatric Medications

Background Psychiatric medications, such as antipsychotics and antidepressants, are associated with QTc interval prolongation. There is currently no consensus best practice on how to mitigate this risk. This study aimed to collect and analyze information about methods used for QTc monitoring in patients taking psychiatric medications to better understand current practice. Methods An anonymous electronic survey was distributed on September 22, 2022, using a national psychiatric pharmacist organization email list. The survey closed on December 15, 2022. Descriptive statistics were used to analyze the multiple-choice questions. Qualitative analysis applying grounded theory for thematic analysis was performed for free response questions. Results A total of 48 initiated the survey. Of the respondents, 11.4% (5/44) reported that their institution had a formal protocol for monitoring QTc intervals in patients receiving psychiatric medications, while 32.4% (12/37) reported that their institution had an informal process. Out of those with a protocol or process, approximately half reported that it was drug-specific. Among the respondents, 88.6% (31/35) reported that there was a psychiatric clinical pharmacy specialist at their institution and 34.3% (12/35) reported that pharmacists could order an electrocardiogram (ECG). Major themes that emerged from the qualitative analysis included pharmacist-driven QTc monitoring, referring the patient to another provider for monitoring, and encountering significant barriers to monitoring. Conclusion A variety of methods are currently being employed to monitor QTc prolongation risk in patients taking psychiatric medications. Pharmacist authorization to order ECGs may be an opportunity to advance practice and improve care for this population. Further research is needed to more clearly understand best practices for QTc prolongation risk mitigation in patients receiving psychiatric medications.

Comparison of Novel Telemonitoring System Using the Single-lead Electrocardiogram Patch With Conventional Telemetry System

BACKGROUND AND OBJECTIVES

Although a single-lead electrocardiogram (ECG) patch may provide advantages for detecting arrhythmias in outpatient settings owing to user convenience, its comparative effectiveness for real-time telemonitoring in inpatient settings remains unclear. We aimed to compare a novel telemonitoring system using a single-lead ECG patch with a conventional telemonitoring system in an inpatient setting.

METHODS

This was a single-center, prospective cohort study. Patients admitted to the cardiology unit for arrhythmia treatment who required a wireless ECG telemonitoring system were enrolled. A single-lead ECG patch and conventional telemetry were applied simultaneously in hospitalized patients for over 24 hours for real-time telemonitoring. The basic ECG parameters, arrhythmia episodes, and signal loss or noise were compared between the 2 systems.

RESULTS

Eighty participants (mean age 62±10 years, 76.3% male) were enrolled. The three most common indications for ECG telemonitoring were atrial fibrillation (66.3%), sick sinus syndrome (12.5%), and atrioventricular block (10.0%). The intra-class correlation coefficients for detecting the number of total beats, atrial and ventricular premature complexes, maximal, average, and minimal heart rates, and pauses were all over 0.9 with p values for reliability <0.001. Compared to a conventional system, a novel system demonstrated significantly lower signal noise (median 0.3% [0.1-1.6%] vs. 2.4% [1.4-3.7%], p<0.001) and fewer episodes of signal loss (median 22 [2-53] vs. 64 [22-112] episodes, p=0.002).

CONCLUSIONS

The novel telemonitoring system using a single-lead ECG patch offers performance comparable to that of a conventional system while significantly reducing signal loss and noise.

TRIAL REGISTRATION

Clinical Research Information Service Identifier: KCT0008176.

Standard practices in cardiac monitoring: training needs of intensive care unit nurses

BACKGROUND

Enforcing practice standards for cardiac monitoring in intensive care units (ICUs) has been shown to reduce misdiagnoses and inappropriate interventions. Continuous professional development (CPD) programs are committed to aligning clinical practices with recommended standards. The crucial initial phase in CPD development involves assessing the training needs of the targeted population.

OBJECTIVE

To assess the training needs of ICU nurses in cardiac monitoring. The overarching goal was to formulate a focused Continuous Professional Development (CPD) program geared towards implementing standard practices in cardiac monitoring.

METHODS

This study employed a generic qualitative approach with a descriptive design, utilizing interviews and focus groups from July to September 2018. Involving 16 ICU nurses. Content analysis was employed, encompassing transcription, fluctuant and iterative reading, unitization, categorization, coding, description, and interpretation.

RESULTS

All nurses recognized cardiac monitoring's importance in the ICU but reported barriers to its effective implementation which were related to factors that could addressed by a CPD as insufficient knowledge and skills. Training needs were identified in both clinical and technical aspects, with recommendations for practical and theoretical activities and e-learning strategies. Barriers related to organizational aspects (equipment and communication within the healthcare team) were also mentioned.

CONCLUSION

ICU nurses presented clear and specific training needs related to cardiac monitoring as knowledge, skills, and competencies. Other organizational aspects were also reported as barriers. Addressing these learning needs through targeted CPD aligned with organizational initiatives can contribute to enhancing the quality of cardiac monitoring practices in ICUs.

Holter ECG monitoring and platelets characteristics in patients with coronary artery disease and atrial fibrillation

OBJECTIVE

Aim: To check the relationships between platelet characteristics and Holter ECG monitoring results in patients with atrial fibrillation (AF) and coronary artery disease (CAD).

PATIENTS AND METHODS

Materials and Methods: 300 investigated patients were separated into three groups: I (CAD) - 149 patients with CAD without arrhythmias, II (CAD and AF) - 124 patients with CAD and AF paroxysm, and the control group (CG) - 27 patients without CAD and arrhythmias.

RESULTS

Results: In the II group was detected an increase in mean platelet volume (MPV) (9.30%) and platelet-to-leucocyte ratio (PLR) (41.12%) and a decrease in platelet count (PC) (12.20%) in comparison with the I group, P<0.05. Also, in the II group was found an increase in platelet leucine (12.63%), isoleucine (10.73%), and a decrease in serine (5.06%), threonine (23.05%), valine (30.83%), glycine (32.21%) levels in comparison with the I group, P<0.05. PC, MPV, and PLR ratios were correlated with supraventricular extrasystoles per hour (r=-0.352, r=0.308, and r=0.359, consequently), P<0.05. Platelets distribution width (PDW) was correlated with ST-segment changes (r=0.371), P<0.05. Platelet threonine, serine, glycine, alanine, and valine levels were correlated with total supraventricular extrasystoles (r=-0.374, r=-0.358, r=-0.402, r=-0.307, r=-0.312, consequently) and supraventricular extrasystoles per hour (r=-0.374, r=-0.358, r=-0.402, r=-0.307, r=-0.312, consequently), P<0.05. Platelet lysine, taurine, cysteine, and phenylalanine levels were correlated with ST-segment changes (r=-0.319, r=-0.344, r=-0.376, and r=0.317, consequently), P<0.05.

CONCLUSION

Conclusions: Platelet features (PC, MPV, PDW, PLR, and amino acid spectrum) are significantly correlated with supraventricular arrhythmias and ST-segment episodes, which shows their role in AF and CAD pathogenesis.

Occult myocardial injury is prevalent amongst elderly patients in the hospital-at-home setting. A retrospective analysis of 213 patients

Background

Hospital-at-Home (HAH) is a valid alternative for in-hospital stay for a wide variety of clinical indications. Occult myocardial injury, associated with acute illness, mainly occurs in patients with a background of non-obstructive coronary disease. The aim of this study was to describe the prevalence of this phenomenon in our HAH population.

Methods

A retrospective description and analysis of data collected for patients admitted to the Sheba beyond's HAH services during 14 months.

Results

During a period of 14 months (7/10/21-6/12/22), blood troponin measurements were available for 213 patients (median age 78 years, 52% males) hospitalized mainly for infectious causes. The median HS (highly sensitive) troponin level was 7.7 ng/L (IQR = 13.2 ng/L) (the normal upper limit is 12 ng/L) with 31% of all patients demonstrating an abnormally increased troponin level (68/213). Of all patients, 64% had a background diagnosis of a cardiovascular disease (138/213), of whom, 49% had abnormal HS troponin levels (68/138). No patient suffered from acute cardiac function deterioration and no patient died during their hospital-at-home stay.

Conclusion

The prevalence of occult myocardial injury amongst elderly patients admitted to hospital-at-home stay for diagnoses other than myocardial infarction is relatively high but it is not associated with worse short-term clinical outcomes.

Ventricular tachycardia and in-hospital mortality in the intensive care unit

Background

Continuous electrocardiographic (ECG) monitoring is used to identify ventricular tachycardia (VT), but false alarms occur frequently.

Objective

The purpose of this study was to assess the rate of 30-day in-hospital mortality associated with VT alerts generated from bedside ECG monitors to those from a new algorithm among intensive care unit (ICU) patients.

Methods

We conducted a retrospective cohort study in consecutive adult ICU patients at an urban academic medical center and compared current bedside monitor VT alerts, VT alerts from a new-unannotated algorithm, and true-annotated VT. We used survival analysis to explore the association between VT alerts and mortality.

Results

We included 5679 ICU admissions (mean age 58 ± 17 years; 48% women), 503 (8.9%) experienced 30-day in-hospital mortality. A total of 30.1% had at least 1 current bedside monitor VT alert, 14.3% had a new-unannotated algorithm VT alert, and 11.6% had true-annotated VT. Bedside monitor VT alert was not associated with increased rate of 30-day mortality (adjusted hazard ratio [aHR] 1.06; 95% confidence interval [CI] 0.88-1.27), but there was an association for VT alerts from our new-unannotated algorithm (aHR 1.38; 95% CI 1.12-1.69) and true-annotated VT(aHR 1.39; 95% CI 1.12-1.73).

Conclusion

Unannotated and annotated-true VT were associated with increased rate of 30-day in-hospital mortality, whereas current bedside monitor VT was not. Our new algorithm may accurately identify high-risk VT; however, prospective validation is needed.

Completing the Cabrera Circle: deriving adaptable leads from ECG limb leads by combining constraints with a correction factor

Objective.We present a concept for processing 6-lead electrocardiography (ECG) signals which can be applied to various use cases in quantitative electrocardiography.Approach.Our work builds upon the mathematics of the well-known Cabrera sequence which is a re-sorting of the six limb leads (I,II,III,aVR,aVL,aVF) into a clockwise and physiologically-interpretable order. By deriving correction factors for harmonizing lead strengths and choosing an appropriate basis for the leads, we extend this concept towards what we call the 'Cabrera Circle' based on a mathematically sound foundation.Main results.To demonstrate the practical effectiveness and relevance of this concept, we analyze its suitability for deriving interpolated leads between the six limb leads and a 'radial' lead which both can be useful for specific use cases. We focus on the use cases of i) determination of the electrical heart axis by proposing a novel interactive tool for reconstructing the heart's vector loop and ii) improving accuracy in time of automatic R-wave detection and T-wave delineation in 6-lead ECG. For the first use case, we derive an equation which allows projections of the 2-dimensional vector loops to arbitrary angles of the Cabrera Circle. For the second use case, we apply several state-of-the-art algorithms to a freely-available 12-lead dataset (Lobachevsky University Database). Out-of-the-box results show that the derived radial lead outperforms the other limb leads (I,II,III,aVR,aVL,aVF) by improving F1 scores of R-peak and T-peak detection by 0.61 and 2.12, respectively. Results of on- and offset computations are also improved but on a smaller scale.Significance.In summary, the Cabrera Circle offers a methodology that might be useful for quantitative electrocardiography of the 6-lead subsystem-especially in the digital age.

Differences in Postoperative Atrial Fibrillation Incidence and Outcomes After Cardiac Surgery According to Assessment Method and Definition: A Systematic Review and Meta-Analysis

BACKGROUND

Postoperative atrial fibrillation (POAF) is the most frequent complication of cardiac surgery. Despite clinical and economic implications, ample variability in POAF assessment method and definition exist across studies. We performed a study-level meta-analysis to evaluate the influence of POAF assessment method and definition on its incidence and association with clinical outcomes.

METHODS AND RESULTS

A systematic literature search was conducted to identify studies comparing the outcomes of patients with and without POAF after cardiac surgery that also reported POAF assessment method. The primary outcome was POAF incidence. The secondary outcomes were in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay. Fifty-nine studies totaling 197 774 patients were included. POAF cumulative incidence was 26% (range: 7.3%-53.1%). There were no differences in POAF incidence among assessment methods (27%, [range: 7.3%-53.1%] for continuous telemetry, 27% [range: 7.9%-50%] for telemetry plus daily ECG, and 19% [range: 7.8%-42.4%] for daily ECG only; P>0.05 for all comparisons). No differences in in-hospital mortality, stroke, intensive care unit length of stay, and postoperative length of stay were found between assessment methods. No differences in POAF incidence or any other outcomes were found between POAF definitions. Continuous telemetry and telemetry plus daily ECG were associated with higher POAF incidence compared with daily ECG in studies including only patients undergoing isolated coronary artery bypass grafting.

CONCLUSIONS

POAF incidence after cardiac surgery remains high, and detection rates are variable among studies. POAF incidence and its association with adverse outcomes are not influenced by the assessment method and definition used, except in patients undergoing isolated coronary artery bypass grafting.

Possible Delay in Symptomatology of a Methadone Overdose in a Patient Ingesting an Energy Drink and Dextroamphetamine/Amphetamine

Introduction: Methadone is a mu-opioid agonist with a delayed time to peak concentration that requires an extended period of monitoring following an overdose. Available data suggests that the combination of psychostimulants with methadone may augment antinociception and tolerance to opioids. Case Report: A 26-year-old male (83.9 kg) presented to the ED approximately 1 hour after unintentionally ingesting 200-250 mg of liquid methadone and an energy drink, along with 20 mg of dextroamphetamine/amphetamine prior to the event. Vital signs were: blood pressure (BP), 143/91 mmHg; heart rate (HR), 74; respirations (RR), 16; oxygen saturation 95% on room air. His urine drug screen was positive for amphetamines and methadone. Patient was monitored for 4 hours with no change in status and was discharged home. Approximately 26 hours later patient was found cyanotic and apneic. Patient was given 2 mg of naloxone and awoke with normal mental status. On presentation the patient's vital signs were: BP, 114/70 mmHg; HR, 114; RR 16; oxygen saturation 94% on 3 liters nasal cannula. During his ED stay, he required 2 doses of naloxone secondary to oxygen desaturation and was admitted to the hospital. His repeat urine drug screen was positive for amphetamines and methadone. The patient was discharged the following day. Discussion: This case illustrates an unintentional methadone overdose combined with the intentional ingestion of an energy drink and dextroamphetamine/amphetamine that possibly masked the toxicity for over 24 hrs. Monitoring parameters for methadone overdoses may need re-evaluation in the setting of the co-ingestion of a stimulant.

Corrected QTc interval combined with troponin value and mortality in acute ischemic stroke

Background and Purpose

Cardiac biomarkers including, elevated troponin (ET) and prolonged heart rate-corrected QT (PQTc) interval on electrocardiography are known to frequent and have a prognostic significance in patients with acute ischemic stroke (AIS). However, it is still challenging to practically apply the results for appropriate risk stratification. This study evaluate whether combining ET and PQTc interval can better assess the long-term prognosis in AIS patients.

Methods

In this prospectively registered observational study between May 2007 and December 2011, ET was defined as serum troponin-I ≥ 0.04 ng/ml and PQTc interval was defined as the highest tertile of sex-specific QTc interval (men ≥ 469 ms or women ≥ 487 ms).

Results

Among the 1,668 patients [1018 (61.0%) men; mean age 66.0 ± 12.4 years], patients were stratified into four groups according to the combination of ET and PQTc intervals. During a median follow-up of 33 months, ET (hazard ratio [HR]: 4.38, 95% confidence interval [CI]: 2.94-6.53) or PQTc interval (HR: 1.53, 95% CI: 1.16-2.01) alone or both (HR: 1.77, 95% CI: 1.16-2.71) was associated with increased all-cause mortality. Furthermore, ET, PQTc interval alone or both was associated with vascular death, whereas only ET alone was associated with non-vascular death. Comorbidity burden, especially atrial fibrillation and congestive heart failure, and stroke severity gradually increased both with troponin value and QTc-interval.

Conclusions

In patients with AIS, combining ET and PQTc interval on ECG enhances risk stratification for long-term mortality while facilitating the discerning ability for the burden of comorbidities and stroke severity.

Ten Years Later, Alarm Fatigue Is Still a Safety Concern

Ten years after the publication of a landmark article in AACN Advanced Critical Care, alarm fatigue continues to be an issue that researchers, clinicians, and organizations aim to remediate. Alarm fatigue contributes to missed alarms and medical errors that result in patient death, increased clinical workload and burnout, and interference with patient recovery. Led by the American Association of Critical-Care Nurses, national patient safety organizations continue to prioritize efforts to battle alarm fatigue and have proposed alarm management strategies to mitigate the effects of alarm fatigue. Similarly, clinical efforts now use simulation studies, individualized alarm thresholds, and interdisciplinary teams to optimize alarm use. Finally, engineering research efforts have innovated the standard alarm to convey information more effectively for medical users. By focusing on patient and provider safety, clinical workflow, and alarm technology, efforts to reduce alarm fatigue over the past 10 years have been grounded in an evidence-based and personnel-focused approach.

Environmental pollutant pre- and polyfluoroalkyl substances are associated with electrocardiogram parameters disorder in adults

Environmental pollutants exposure might disrupt cardiac function, but evidence about the associations of per- and polyfluoroalkyl substances (PFASs) exposure and cardiac conduction system remains sparse. To explore the associations between serum PFASs exposure and electrocardiogram (ECG) parameters changes in adults, we recruited 1229 participants (mean age: 55.1 years) from communities of Guangzhou, China. 13 serum PFASs with detection rate > 85% were analyzed finally. We selected 6 ECG parameters [heart rate (HR), PR interval, QRS duration, Bazett heart rate-corrected QT interval (QTc), QRS electric axis and RV5 + SV1 voltage] as outcomes. Generalized linear models (GLMs) and Bayesian kernel machine regression (BKMR) model were conducted to explore the associations of individual and joint PFASs exposure and ECG parameters changes, respectively. We detected significant associations of PFASs exposure with decreased HR, QRS duration, but with increased PR interval. For example, at the 95th percentile of 6:2 Cl-PFESA, HR and QRS duration were - 6.98 [95% confidence interval (CI): - 9.07, - 4.90] and - 6.54(95% CI: -9.05, -4.03) lower, but PR interval was 7.35 (95% CI: 3.52, 11.17) longer than those at the 25th percentile. Similarly, significant joint associations were observed in HR, PR interval and QRS duration when analyzed by BKMR model.

Markov model for detection of ECG instability prior to cardiac arrest in single-ventricle patients

OBJECTIVES

Assess the degree of instability in the electrocardiogram (ECG) waveform in patients with single-ventricle physiology before a cardiac arrest and compare them with similar patients who did not experience a cardiac arrest.

METHODS

Retrospective control study in patients with single-ventricle physiology who underwent Norwood, Blalock-Taussig shunt, pulmonary artery band, and aortic arch repair from 2013 to 2018. Electronic medical records were obtained for all included patients. For each subject, 6 h of ECG data were analyzed. In the arrest group, the end of the sixth hour coincides with the cardiac arrest. In the control group, the 6-h windows were randomly selected. We used a Markov chain framework and the likelihood ratio test to measure the degree of ECG instability and to classify the arrest and control groups.

RESULTS

The study dataset consists of 38 cardiac arrest events and 67 control events. Our Markov model was able to classify the arrest and control groups based on the ECG instability with an ROC AUC of 82% at the hour preceding the cardiac arrests.

CONCLUSION

We designed a method using the Markov chain framework to measure the level of instability in the beat-to-beat ECG morphology. Furthermore, we were able to show that the Markov model performed well to distinguish patients in the arrest group compared to the control group.